The Hospital Planning Process

The Hospital Planning Process Seminar Indian Institute of Health Management Research Jaipur, March 15, 2008 Presented by Martin Fiset, Architect, Healthcare Facilities Planning and Consultant Montréal QC Canada Project Stages New or Expansion Strategic Planning Definition Commissioning Operation 2 Programme for the Seminar Strategic Planning External Environment Internal Environment Project Definition Master Program Master Plan Functional and Space Program Programme for the Seminar Procurement methods Stages Approaches Stages Operation Building commissioning Operational commissioning 3 4 1

Basic Philosophy Reflection before action Analysis before synthesis Diagnostic before treatment Programming before planning & design Treat the disease, not the symptoms Define and understand the problems before developing solutions Planning Process New Institution Master Program Functional Program Strategic Plan Inventory and Evaluation Site 5 6 Needs vs Resources Needs Resources Existing and Future Strategic Planning The process by which the guiding members of an organization envision its future and develop the necessary procedures to achieve that future It helps an organization create its future Goodstein, Nolan and Pfeiffer 7 8 2

Strategic Planning Strategic Planning Assess the external environment (Events over which you have no control) Demographics Epidemiology Social and political trends Healthcare delivery trends Markets and potential customers Competitors Market share Regulatory constraints Assess the internal environment (Events over which you have complete or partial control) Strengths and weaknesses Organizational structure Workloads and utilization Current resources Financial Human 9 10 Strategic Planning " Outcome Vision, mission and objectives Future scope of services Workloads and utilization objectives Financial feasibility Framework to Forecast Needs Current Utilization Current Population x Current Use Rates x Current Market Share = Inpatient Volumes Surgery Volumes Clinic Visits ALOS Total Patient Days Disease incidence Population health Inpatient use rates Alternative to hospitalization New treatments New entrants to market Future Utilization Population Projections x Future Use Rates x Future Market Share = Inpatient Volumes Surgery Volumes Clinic Visits ALOS Total Patient Days 11 12 3

Planning Process Existing Institution Master Program Strategic Plan Inventory and Evaluation Site and Buildings Master Program Definition Goals Contents Prerequisites Caveats Process Facility Master Plan 13 14 Definitions Program: Specification of what should be included in the plan. Master Program: Summary description of functional components to be included in the plan along with planning criteria and major organizational concepts. Plan: A written description accompanied or not by graphics describing a future state that is desirable. Facility Master Plan: Definition of all physical resources necessary to achieve the stated role of the institution Master Program Definition Preliminary functional program that defines the project components and their areas based on workloads and general operating principles and systems, and provides an overall definition of the total project An assessment by department of the implications of the hospital s strategic plan on the departmental scope of services, workload and facility requirements: major room elements and departmental area 15 16 4

Master Program Goals Translate the clinical program into functional and space needs; Provide a rational basis for developing a master plan for an existing institution or an architectural concept for a new building. Provide to the institution, funding organizations, design professionals and other stakeholders a document describing and quantifying the physical resources the institution requires to carry out its role. Master Program Content Summaries Clinical programs Operational systems Pharmacy Materiel handling Food Linen Sterile supplies IT Workloads Number of beds distributed by categories Summary of all major rooms (operating rooms, imaging, etc.) 17 18 Master Program Component Programs Overview and assumptions Scope of Services; Major Policies and Procedures Workloads Staffing InterDdepartmental relationships Gross Area Major sectors Inpatients Units Ambulatory Care Diagnostic and Therapeutic Services Administrative Services Support Services Patient and Public Services Staff Services Master Program Space Needs Future space needs ensue from: Changes in programs and services: Existing ones that expand, contract or are abandoned New ones Correction of functional and physical deficiencies Needs should be distributed over different planning horizons: 5D10D20 years 19 20 5

Master Program Space Needs + _ Anticipated Space Needs 0 5 10 15 20 25 Short Term Component Areas Medium Term Long Term 0 5 10 15 20 25 Master Program Prerequisites Strategic plan defining clinical services and workloads Organizational structure with appropriate authority to settle issues unresolved at the users level Internal or external programming expertise Efficient communication links between participants 21 22 Master Program Caveats Recognize the goals pursued by the master program and its level of precision: the Master Program is not a detailed functional program Take into consideration time lapses between master program, master plan, functional program and project design and construction Master Program Caveats Avoid useless discussions on details that will be resolved at the functional program stage Use projected workloads, staffing and equipment, and generally accepted standards to determine future space requirements 23 24 6

Master Program Process Structured users participation: To develop a more complete and well documented program To get the users to buy in the program and the subsequent plan To avoid communication problems Participation through questionnaires and interviews Master Program Process Users Contribution: Historical workloads Operational policies and procedures Factors that will impact workloads (and not the projected workloads themselves) Evaluation of different design criteria and factors that will impact space (but not the space requirements themselves) 25 26 Master Program Outcome Recapitulation of the Strategic Plan Demographic and epidemiological data Current and projected scope of services Projected workloads Number of beds For each department/service: Services offered Current and projected workloads Major rooms or other appropriate space determinant Current and projected gross area Space List Summary 1. I N P A T I E N T U N I T S 348,027 32333 # Beds 1.1 Medical/Surgical Units 504 192612 17894 1.2 Obstetrical Unit 30 22770 2115 1.3 Neonatal Intensive Care Unit 20 5115 475 1.4 Paediatric Unit 48 11137 1035 1.5 Intermediate Care Units 48 22103 2053 1.6 Intensive Care Units 96 57567 5348 1.7 Coronary Care Unit 32 18693 1737 1.8 Palliative Care Unit 8 4560 424 1.9 VIP Unit 14 13470 1251 800 27 28 7

Space List Summary 2. AMBULATORY CARE Total Components Gross Area 110174 10235 Beds/Stretchers 2.1 General Medical Clinics 12210 1134 2.2 General Surgical Clinics 15,945 1481 2.3 Specialty Clinics 15,930 1480 2.4 Medical/Surgical Day Care 24 MDC 18,383 1708 2.5 Emergency 16 Observ. 17,004 1580 2.6 Dialysis Service 12 Treatment 7,335 681 2.7 Oncology Centre 20 Treatment 6,405 595 2.8 Specimen Collection 2,828 263 2.9 Pre"Operative Assessment Unit 1,834 170 2.10 Executive Health Check"Up 8,685 807 2.11 In"Vitro Fertilization Centre 3,615 336 Total 109 Space List Summary 3. DIAGNOSTIC AND TREATMENT SERVICES Total Gross Area 170,921 15879 3.1 Surgical Suite 47,584 4421 3.2 Diagnostic Imaging 31,504 2927 3.3 Clinical Labs 26,156 2430 3.4 Pharmacy 7,621 708 3.5 Morgue and Autopsy 2,795 260 3.6 Physiotherapy 5,656 525 3.7 Occupational Therapy 1,778 165 3.8 Audiology and Speech Therapy 4,077 379 3.9 Electrodiagnostic Services 5,032 467 3.10 Respiratory Therapy 3,038 282 3.11 Cardiac Catheterization Lab 9,663 898 3.12 Social Work 819 76 3.13 Endoscopy and Cystoscopy Suite 6,825 634 29 30 Space List Summary Space List Summary 4. ADMINISTRATIVE SERVICES Total Components Gross Area 37691 3502 4.1 Administration 14924 1386 4.2 Amitting/Registration 4,172 388 4.3 Educational Services 9,974 927 4.4 Health Records 4,953 460 4.5 Employees' Health Service 1,162 108 4.6 Information Systems 2,506 233 5. SUPPORT SERVICES Total Components Gross Area 88175 8192 5.1 Central Stores and Distribution 22241 2066 5.2 Central Sterilization Service 10506 976 5.3 Dietary Service for Patients 10506 976 5.4 Dietary Service for Staff 21600 2007 5.5 Laundry and Linen Service 13125 1219 5.6 Housekeeping 805 75 5.7 Engineering and Maintenance 7488 696 5.8 Security 1904 177 31 32 8

Space List Summary Space List Summary 6. STAFF and PUBLIC SERVICES Total Components Gross Area 58221 5409 6.1 Medical Staff Services 6994 650 6.2 Hospital Staff Services 16440 1527 6.3 Public and Patients Services 34788 3232 Total Components Gross Area 813209 75550 Main Circulations, Exit Stairs, Elevators Cores, etc. 15% 121981 11332 Electrical and Mechanical Systems 10% 93519 8688 Total Building Gross Area 1028710 95570 33 34 Other Plans Manpower plan A description of the implications of the hospital s future directions for staff (medical and allied health) recruitment, training and replacement Financial plan A plan for securing the necessary funding for capital investment and operation Inventory and Evaluation Existing Institution Master Program Strategic Plan Facility Master Plan Inventory and Evaluation Site and Buildings 35 36 9

Inventory and Evaluation New Institution Needs vs Resources Strategic Plan Master Program Inventory and Evaluation Site Needs Functional Program Resources Existing and Future 37 38 Physical and Functional Evaluation Land Buildings Inventory and Evaluation Goals Get a clear and well documented picture of the physical resources the institution has at its disposal to fulfill its role Identify the functional and physical deficiencies that will need to be corrected or palliated by the master plan Identify constraints imposed by the buildings and the site on future development 39 40 10

Inventory and Evaluation Process Inventory done first Physical evaluation by team of architects and engineers early in the process, assisted by staff responsible for planning and maintenance, using preddetermined forms Inventory of Buildings and Site Collect all available plans for buildings and site Examine to see if they are complete and up to date Survey site, buildings or parts of buildings as required Assign rooms to specific functional components Tally site information and functional components areas 41 42 Site Data to be Collected Existing or New Site Survey Zoning Easements/Rights of way Access points Topography Drainage Soil Vegetation Services and utilities Transportation Evaluation Site Area Zoning, easements and other legal constraints Accessibility Topography Soil characteristics Vegetation Services Parking and public transport Environmental quality Expansion potential 43 44 11

Location Site Plan 45 46 Dates of Site Access and Entry Points 47 48 12

Buildings Physical Evaluation Architecture Envelope Interior finishes Fixed equipment Means of conveyance Codes Physical Evaluation Buildings Structure Foundations Vertical and horizontal elements Bearing capacity Codes 49 50 Physical Evaluation Buildings Mechanical Systems Heating Ventilation Air conditioning Plumbing Other services Codes Physical Evaluation Buildings Electrical Systems Power supply and distribution Emergency power Lighting Communications Fire alarm Codes 51 52 13

Functional Evaluation Done during the master programming stage For each functional component: Areas of individual rooms and of whole component Functional relationships with other components Component layout Flexibility/adaptability Environmental quality Expansion potential Documentation Tabulation of areas (see Master Program) Diagram of functional relationships, existing and desirable Summary tables for physical evaluation to identify at a glance where major deficiencies are Description of functional and physical deficiencies according to divisions listed previously 53 54 Graphic Documentation Master Plan Role Needs Resources Master Program Inventory and Evaluation Additional resources Master Plan 55 56 14

Master Plan Existing Institution Master Plan New Institution Master Program Inventory and Evaluation Site and Buildings Master Program Inventory and Evaluation Site Facility Master Plan Functional Program Functional Program 57 58 Master Plan What is a master plan and what should it consist of? When should it be undertaken? What should the process be? Who should participate? Why should an institution have a master plan? Why is it important? Master Plan Role To chart the course the institution should follow for its rejuvenation and expansion and, in some cases, for its total replacement on its own site It is akin to an urban plan that defines major axes of circulation and land uses, i.e. a general arrangement of functions and components 59 60 15

Master Plan Phases The Master Plan reflects the needs expressed in the Master Program As the Master Program, it usually comprises several phases to deal with the shortd, mediumd and longdterm needs Usually, a first phase should involve new construction to initiate the musical chair process and avoid multiple decanting Master Plan Goals Respond to institutional priorities and future needs Regroup services/components according to their functional affinities May call for the demolition of obsolete buildings or wings Correct functional and physical deficiencies Improve site accessibility and meet parking requirements 61 62 Guiding Principles General Add to the most recent wing or building Don t surround an old building Don t adjoin an existing building too closely Beware of the floordtodfloor height Start a new wing that can become the nucleus of a total or partial replacement Concentrate expansion in one area; don t build lumps and bumps Guiding Principles Internal Develop major horizontal spines and vertical transportation cores that can serve future expansion Put services/components most likely to expand at the periphery Provide soft space next to component likely to expand Give services/components shapes appropriate to their functions Locate like spaces together 63 64 16

Guiding Principles Site Provide parking to meet current and future requirements Plan for future access points Locate expansion in an area that has expansion potential Respect and take advantage of topography Preserve vegetation Take orientation into consideration A Fine Balance To renovate or to replace? 65 66 Options Master Plan Options RENOVATION ADDITIONAL RESOURCES EXPANSION Leave component where it is and expand in adjacent space? Move component to another location within the hospital? Locate component in new construction? REPLACEMENT 67 68 17

Master Plan Criteria Keep space at the same service level or downgrade space to lower service requirements Leave highly serviced space in place and expand into adjacent area Move lowerdserviced components out of the hospital to make way for other services expansion Master Plan Caveats Beware of: Corridor widths Structural bays LoadDbearing walls FloorDtoDfloor height Elevators capacity HVAC capacity Type of construction Codes 69 70 Master Plan Caveats Beware of: Mechanical/plumbing shafts Electrical/communication panels Floor loaddbearing capacity Special services, e.g. medical gases Door widths Wall and ceiling construction (fire and acoustical rating) Access during demolition and construction Disruption of ondgoing operation Master Plan Process Familiarisation with all previous reports, particularly the Master Program Familiarisation with the existing physical plant Development of various options Presentation to and evaluation by a Steering Committee 71 72 18

Master Plan Process Refinement of selected option(s) Presentation to and evaluation by Steering Committee Refinement of final solution Final presentation Documentation Master Plan Importance Identifies the most pressing problems Establishes a framework for future developmentdrelated decisions Confirms site and building development potential Identifies new development potential Establishes financial and physical guidelines 73 74 Master Plan Importance Solution Ground Floor Can be used to resist pressures from staff to undertake ad hoc projects Improves staff morale Sends a message of renewal and excellence to the local population Provides a promotional document for fund raising 75 76 19

Existing Building Solution Second Floor 77 78 Functional Program Master Program Functional Program Facility Master Plan Inventory and Evaluation Site and Buildings Programming A process leading to the statement of an architectural problem and the requirements to be met in offering a solution Webster Programming = problem seeking = problem solving Programming = analysis = synthesis William Pena 79 80 20

Functional Program Definition Written document that describes the services offered, defines policies and procedures that will be implemented, and identifies all the resources necessary to deliver the services. A document that describes the functions, operations, activity, staffing, room and space requirements of each department or service in a building It must contain all the information necessary to build and operate the facility Functional Program Uses For design professionals, it provides all the information necessary to design the building For the administration, it defines the project objectives and scope For the staff, it identifies policies and procedures to be implemented 81 82 Functional Program Uses For financial planners, it defines human resources and operating cost. For the cost consultants, it provides all the information necessary to prepare realistic cost estimates For funding agencies, it establishes the capital resources necessary to bring the project to fruition Functional Program Communication Tool Goals of the project Operational requirements Functions that will take place in the spaces Description of the facility Operational policies and procedures Workloads Staffing patterns Intradepartmental and interdepartmental relationships Traffic flows Methods for ensuring flexibility and expandability Statement of building requirements 83 84 21

Functional Program Process Identify a Steering Committee Establish project parameters Determine departmental user groups Document department/service role and program Philosophy Policies Systems Procedures Functional Program Process Analyze current and historical activities Project future activity Document existing staffing Project future staffing Document design considerations List all room required with net area and occupancy 85 86 Functional Program Contents Functional Program Contents for each Department/Service Scope of the project Clinical activity Bed distribution Staffing summary Space summary Net and gross areas Total building area Functional relationships Technology Operational policies Patient transport Movement of supplies Movement of samples, records and medication Collection and disposal of waste Information systems Security Communication 87 Component programs Basic hypotheses Services offered Policies and procedures Workload Staffing Functional relationships criteria List of rooms with areas Functional diagram 88 22

Functional Program Primary Space Determinants Operating rooms: surgical procedures Day surgery: outpatient procedures Radiology: diagnostic procedures Pharmacy: prescriptions Physiotherapy: attendances by treatment modality Occupational therapy: visits by treatment modality Obstetrics: number of births Laundry: daily pounds of linen Dietary: number of meals Emergency: visits by type Administrative services: staff Data Sheets Definition Detailed description of every room in the building with all its architectural and engineering requirements, and with a list of equipment and furniture Architectural characteristics such as finishes, doors, hardware, etc. Mechanical and electrical requirements regarding HVAC, medical gases, plumbing, lighting, outlets, etc. Information technology and telecommunication requirements Fixed and mobile equipment Furniture Diagrammatic layout 89 90 Data Sheets Types Generic Done at the functional programming stage Include generic performance requirements Don t include specific materials, finishes, etc. Specific Done at the final design stage Include specific requirements for all room elements Data Sheets Definition See example from MediCity Room Data Sheet Sample.doc 91 92 23

Programming Ability to Control Capital Cost versus Engaged Expenditures Programming Usual Effort versus Required Effort Definition Commissioning Operation Definition Commissioning Operation 93 94 Master Plan Existing Institution Master Program Facility Master Plan Inventory and Evaluation Site and Buildings Project Delivery Approaches Traditional approach: designdtenderd build management /build PublicDprivate partnership Functional Program 95 96 24

Traditional Approach Traditional Approach Owner Tendering Architect Contractor Sequential process Known price before construction begins Longer construction period Architect supervises construction 97 98 Management Manager as Consultant Management Manager as Contractor Owner Owner Architect Contractor Manager Consultant Architect Manager Contractor 99 100 25

/Build Single Provider /Build Single Provider Owner Builder Tendering Tendering Overlaps as per CM Known price before construction begins if GMP Shortest construction period Limited owner s involvement 101 102 Public Private Partnership P3/PFI/BOOT Very popular in England and Australia for construction of new hospitals Starting in Canada Single entity responsible for financing, design, construction and operation of non clinical services P3 partners own and operate the facility for 30 to 35 years before transfer to the client Keys to Success for PFI Projects UK Government The project has clear boundaries and measurable capital output performance; There is scope for innovation in design which enables the service provider to design away risks and bring new ideas to the way the service is provided; The project has a substantial operating content; There is scope for the service provider to find alternative uses for the asset provided; Any surplus assets intrinsic to the project are included in the package; and, The risks transferred to the private sector are commercial in nature and controllable. 103 104 26

P3 for Hospital Projects in India Experience already in India for infrastructure construction Will the government remain a provider? For private hospitals, P3 are not applicable Block Schematics Preliminary design Final design Contract documents Working drawings Specifications 105 106 Block Schematics Based on the Master Program Developed by architects, engineers and other consultants Schematic drawings showing all components Site plan Outline specifications Validation of preliminary cost estimates Block Schematics See example from MediCity..\..\ARCOP Office\India\\IIMSHT Block Plans 7.8 01APR05 2.pdf 107 108 27

Feasibility Study Preliminary Report General project description Master program Block schematics drawings Outline specifications Preliminary cost estimates Schedule and delivery method Preliminary Internal layout of all departments with all partitions, doors and circulations patterns within department Check for all code regulations Preliminary sections through building and elevations 109 110 Preliminary Example 6.L1_1.5a ICU Type 1.pdf Final Dimensioned drawings Final code verification Final sections and elevations Final choice of materials Final selection of fixed medical equipment Specific data sheets 111 112 28

Final Example AD106_Lvl_1.dwg Contract Documents Complete set of drawings and specifications good for construction May be assembled in packages for a fastdtrack process 113 114 Traditional Approach Tendering Contract award Site supervision Definition Conception Operation 115 116 29

Fast"track Process Overlaps Programming/ Definition Conception MP FP DS Block Schem. Schem. Final Contract Documents Operation 117 118 Overlaps / Overlaps /Operation Block Schem. Final Contract Documents 1 2 Const. 3 1 2 3 Operation Operation 119 120 30

Operation Building commissioning Mechanical and electrical systems Other systems Medical equipment Mobile equipment Supplies Operation Operational commissioning Medical staff recruitment Allied health and other staff recruitment and training Managerial organization 121 122 Thank you for your attention Questions? 123 31